4
Implementing Innovations at the State and Local Levels
The second panel provided a perspective on some of the work happening in states and localities to advance children’s behavioral health. In cities, counties, and states across the country, health care reform has accelerated the movement to provide greater coverage of behavioral health and prevention, speakers on the panel noted. An increasing number of stakeholders, including businesses, are recognizing the many benefits of better behavioral health and are contributing to efforts to improve behavioral health.
INTEGRATED INTERVENTIONS IN OREGON
Oregon has created coordinated care organizations in individual counties or groups of counties that act as health insurers for people on the Oregon Health Plan. About 26 percent of the state’s population, or around one million people, are covered by the plan.
These coordinated care organizations have sought to improve the integration of primary care and behavioral health, and they have resources to do so, said Anthony Biglan, senior scientist at Oregon Research Institute and author of the recent book The Nurture Effect: How the Science of Human Behavior Can Improve Our Lives and the World (New Harbinger, 2015). For example, in Lane County, a coordinated care organization with which the Oregon Research Institute works is funding both prevention efforts in communities and efforts to integrate behavioral health and primary care. This work reflects an increasingly shared understanding of what children need to develop, which is grounds for optimism, said Biglan.
In addition, Oregon created an Early Learning Council to look at all the things needed for young children to develop successfully. Through legislative action, this morphed into the Early Learning Division in the state Department of Education, which is funding county-level hubs to support the development of young children. Hubs are required to focus on three goals: (1) ensuring that all children are socially and academically ready to learn by the time they reach kindergarten; (2) that families are stable and attached; and (3) that services are coordinated and efficient. “It is not simply a matter of the health care system doing a better job but of having a community-wide effort to improve development for young children from the prenatal period through at least age 5,” said Biglan. Measures of the social and cognitive readiness of children for kindergarten, which is only about 50 percent in high-poverty neighborhoods in his county, provide an incentive to reduce the number, he added.
Virtually every young child in a poor family in Oregon now has health coverage. An increasing number also have a medical home, Biglan said. The next question is whether they are getting the developmental screenings they should be. Though the state is getting better at these, considerable challenges remain. One of the most important challenges is ensuring that every young child who has a medical home is being screened for developmental readiness and is getting the services of appropriate behavioral health or developmental specialists when screening indicates that they are needed, said Biglan. He noted that the coordinated care organizations and hubs are collaborating to make this happen and that the most difficult part is getting behavioral health effectively integrated with primary care. “We are trying to develop a system in which we can ensure that the screening take place, that services are delivered, and that those services are effective. This is a sort of infrastructure that is evolving, and I think it is very impressive.”
Biglan emphasized that a growing body of literature supports the idea that preventive interventions promote pro-social behavior. Today, the science exists to ensure that virtually every young person arrives at adulthood with the skills, interests, and health habits needed to live a productive life in caring relationships with other people, he said.
He also pointed to the tobacco control movement as a possible model to emulate. “The beauty of the tobacco control movement was that we had a specific behavior, we could measure it in populations, and we could tell whether or not it was going down.” Health care reform is attempting to deal with many more outcomes than simply tobacco use, such as depression, antisocial behavior, and academic failure, with the goal of affecting all of them in the population of young people, said Biglan, noting that the evidence points to the central role of family and school environments in the development of these seemingly disparate problems. He noted that concentrating on making these environments more nurturing can prevent diverse
problems. “We are not set up to do that to a very great extent, but I think that that is where we need to go.”
BEHAVIORAL HEALTH INITIATIVES IN MASSACHUSETTS
The Cambridge Health Alliance is the last freestanding public safety net entity in Massachusetts, with 15 ambulatory health centers, 2 community hospitals, 4 school-based clinics, and a variety of other types of presence in the community. In the past few years, the alliance has made a major effort to integrate mental health services in the primary care setting, but virtually all this effort has gone toward adults, not toward children and families.
Recently, the state Medicaid program has been rolling out a primary care payment reform that is forging much stronger connections between primary care and mental health providers, noted Gregory Hagan, chief of pediatrics at the Cambridge Health Alliance and clinical instructor in pediatrics at Massachusetts General Hospital and Harvard Medical School. Building on the ACA, the state Medicaid program is putting into effect over the next 3 years an ambitious plan to shift all Medicaid patients to a fully owned risk model. Initially, people are able to sign up for limited amounts of risk, but over time it will become fully capitated, and mental and developmental health care are included in many aspects of the plan. Though not as comprehensive as it should, said Hagan, “It is a very good start.”
Challenges have included a lack of data about expenses, which made it difficult to set rates, particularly for behavioral health. In addition, mental health was not necessarily part of the shared risk. Organizations in Massachusetts such as the Cambridge Health Alliance are well positioned to manage the behavioral health risk as well as the medical risk, “but we politely declined so far because we just don’t know that the numbers will support it,” said Hagan. “It is a work in progress.”
Hagan also has been involved in an effort with the Massachusetts Quality Demonstration Grant under the Children’s Health Insurance Program Reauthorization Act to determine which measures validated in the literature are most useful in real practice settings. As part of that initiative, a large collaborative effort was undertaken to implement medical home principles in 17 very diverse practices across Massachusetts, including private practices, neighborhood centers, and health centers. The measures being used are generally process measures, not outcomes, and many of the measures are composite measures of well child care; still, nested in those measures are data related to child behavioral health development.
Finally, in Hagan’s own practice, he has been working on a project funded by Blue Cross/Blue Shield Foundation of Massachusetts to develop a working model of collaborative practice. A child psychiatrist and a child psychiatry fellow spend two afternoons per week at the practice and are
fully integrated into the team. “We are very excited about how the model is working and have had some good results to share,” he said.
COMBINING PRIMARY CARE AND BEHAVIORAL HEALTH IN OHIO
Kelly Kelleher, a pediatrician at the Nationwide Children’s Hospital, described the pediatric ACO called Partners for Kids. Partners for Kids is a fully capitated physician hospital organization of approximately 800 clinicians, primary care physicians, and specialists. Based at Nationwide Children’s Hospital in Columbus, Ohio, it serves 332,000 Medicaid children in Ohio and a growing number of commercial customers in an accountable care format.
Taking on full capitation risk for a population across a large region has produced three lessons, Kelleher said. Previously, almost none of the agencies admitting children for psychiatric problems, the school-based clinics, and the individual mental health providers knew what the others were doing. “Just putting providers in touch with each other altered the readmission rates for child behavioral health problems,” said Kelleher, in addition to changing the number of referral pathways and linking people better with care. “Provider integration is going to be essential,” he said. “Mom and pop shops for mental health are over. We should be clear about that to all of our training programs, to all of our universities, and to everybody who thinks they can still hang out a shingle by themselves.”
Second, data and metrics have become driving forces. “When you start to look at data, you suddenly find where the emergencies are and where you should focus your priorities.” For example, school data revealed that the largest high school near the hospital where Kelleher works had 6,500 days of children absent in the previous school year because of juvenile justice involvement, which Kelleher termed a “mental health crisis.” The metrics demanded by organizations such as the National Committee for Quality Assurance and the state Medicaid agency are at the claims level and need to be gathered, he said, but data are also needed from schools, foster care, juvenile justice, and other systems that involve children and families, as are data on unemployment, school readiness, high school graduation, teen pregnancy, and other characteristics outside of the traditional health domain.
Finally, prevention has become a priority. “When one-third of your pharmacy costs are devoted to behavioral health drugs and that is the fastest-growing area, when the highest readmission rate of all your major conditions is behavioral health, when behavioral health concerns are number one on all your community doctors’ lists, you suddenly say, we had better pay attention to this. And you realize you can’t hire enough psychia-
trists, enough psychiatric nurse practitioners, and enough specialists to do this, so there is a real commitment now to prevention programs.”
Partners for Kids has adopted several specific programs because of their combination of cost savings and effectiveness. The Good Behavior Game is extremely popular in schools because it reduces disciplinary problems in the classroom and also results in fewer behavioral health referrals from the schools. Adolescent programs involve technology to improve dissemination to rural areas. Pilot programs have connected individuals both to professionals and to online support programs.
According to Kelleher, the ACA “changed the language for non-traditional providers.” People in business are now talking about population health and prevention services in the community with real dollars attached. The Center for Medicare & Medicaid Innovation (CMMI) has appointed a new Director of Population Health, and Ohio leaders are asking whether a population health director is needed. In addition, the state leadership is talking about a children’s council and integrating services for children. Children with disabilities, children under Medicaid, and foster care children are all parts of the discussion, “and juvenile justice is likely next.”
The kinds of changes being discussed require both accountability for outcomes and flexibility in how funds are spent locally, said Kelleher. The right provider, the right payer, and the right partner will differ from one locale to another, and all the payers need to be onboard, so that a single set of incentives exists. “If the commercial insurers are lined up, then it all becomes uniform. It becomes a singular pediatric wellness network rather than 25 different insurance plans.”
The good intentions of policy makers and politicians to make child well-being a priority are not enough, Kelleher argued. Business opportunities need to be identified and pursued, he said. “They are very challenging, but they are there.” For example, Partners for Kids has been careful to measure cost savings. “If we do not measure our savings, then we cannot show how to make the business argument for these programs going forward.”
INTEGRATING PSYCHOLOGISTS WITH MEDICAL TEAMS IN CINCINNATI
When Lori Stark, division director of behavioral medicine and clinical psychology at Cincinnati Children’s Hospital Medical Center, was hired in 1998, there were four psychologists at Cincinnati Children’s. Today there are more than 70, many of whom are providing services for children with chronic illnesses.
A change in 2002 enabled psychologists to bill for medical diagnoses where health and behavior concerns were either the result of or impinging on an illness. This change transformed the way for psychologists to
integrate with medical teams, Stark observed. They no longer had to get advance authorization, which saved them considerable time and costs. Also, they were free to colocate and integrate fully with medical teams. Today, psychologists are part of the medical teams for children with cystic fibrosis, headache, pain, oncology, epilepsy transplant services, and other illnesses. For example, they may work on lifestyle changes to be more adherent to treatment, or they may work on the nuances of a condition and behavior from the first clinical visit.
Children with chronic disease are at higher risk for depression and anxiety, Stark explained, so psychologists can screen patients and give advice to parents in the same visit. Also, the health and behavior codes allow billing in 15-minute increments rather than the 45 minutes in mental health codes. “It may be that we can give parents some advice right there on how to handle a burgeoning anxiety disorder that they can take home and do and not need any further services or follow-up until they come back for their routine medical subspecialty visit.”
When psychologists encounter children who need more services, they can meet in the clinic. In this way, children can avoid stigma while coming to the psychologist’s office for more frequent follow-ups if needed.
This is a good model for prevention and early intervention, said Stark, where providers are colocated and see all children as they come in. For example, ADHD is a prevalent and sometimes overwhelming behavioral health concern in pediatricians’ offices. For about a decade, the ADHD Collaborative has been pulling together psychiatrists, psychologists, neurologists, pediatricians, parents, and others to develop and implement the best approach to the problem. Rather than building a new clinic, providers partnered with pediatricians to integrate the evidence-based guidelines from the American Academy of Pediatrics into their practices. The hospital also recruited a researcher to build an ADHD portal that facilitated communication allowing sharing of information across physician, parents and teachers—which the hospital describes as an evidence-based, comprehensive, and easy-to-use tool for improving the quality of ADHD care—and a randomized clinical trial was under way at the time of the workshop to look at child outcomes as a result of changes in pediatric practice.
In the area of community prevention, a program called Moving Beyond Depression has been targeting maternal depression in first-time mothers and has been attracting interest from other states that want to integrate these services into primary care.1 In general, the ACA has created a much stronger commitment among organizations to their communities, said Stark.
Stark indicated that they have also started incorporating the collection
______________
1Additional information about the Moving Beyond Depression Program can be found at: http://www.movingbeyonddepression.org (accessed September 29, 2015).
of clinical outcomes into routine care, and these outcomes have to be meaningful to the clinicians and to the patients. Otherwise, they amount to just data collection, said Stark. For example, with pediatric pain, psychologists said that the most meaningful metric was functionality—going to school, being social, and so on. As a result the Functional Disability Index was chosen as the outcome measure. “We collect data at every patient visit, and we share the data with our families. We actually show them the screen in Epic and say, ‘This is how we will know when you are getting better.’ It takes the mystery out of treatment.” This approach has shortened lengths of treatment because everyone is directed toward the same goal. It also has demonstrated that improvements in functioning can precede pain reduction.
BARRIERS AT THE STATE AND LOCAL LEVELS
All of the panelists talked about barriers that exist to implementing innovative programs at the state and local level.
Biglan called attention to the larger context, such as children in the juvenile justice or foster care systems. As they age out of these systems, they can find themselves on the streets without health insurance, family support, or other help. In general, poorer people face many stressors that contribute to behavioral and health problems, he said. “The larger context for that is a level of economic inequality and child poverty that is unparalleled among developed nations.”
Hagan pointed out that, even in a fairly liberal state like Massachusetts, services still are directed disproportionately to the needs of the adults and not toward children and adolescents, though some progress has been made. For example, the Massachusetts chapter of the American Academy of Pediatrics initiated a Summit on Early Childhood several years ago that brought in stakeholders from many disciplines. A follow-up to that summit involved the chairman of the Boston Federal Reserve, the governor, and the heads of several tech firms. People like this “understand the need for kids coming out of schools who have competencies in the STEM areas—science, technology, engineering, and mathematics. If you focus on that in your advocacy, that is where you can begin to get traction” with people who can move the policy agenda in a state, Hagan said.
Kelleher recommended holding both public and private meetings to “find the soft spot” of everyone with an influence on policy. “Almost all of them [leaders] have a personal story, and almost all of them have something they really care about.” For example, business leaders have problems that greater attention to child development can help solve. The same applies to state superintendents of schools, state prison boards, and many other people. “They each have a soft spot, and we have to find it, and we have to apply pressure in a positive way.”
Finally, Stark noted that just because policies are in place does not mean they will be implemented. For example, hospitals do not necessarily use the health and behavior codes because they are afraid they will not get paid. “Not only do we need the policies but we need the leadership and the vision within our own organizations to push for implementing those policies.”
Health care 3.0 requires breaking down barriers, said Hagan, “and the only way we are going to do that is if we are fully integrated with these community organizations.” However, Kelleher also pointed out that community organizations are numerous and can disagree with each other in fundamental ways. For example, in many neighborhoods, long-term homeowners dominate the civic associations, and they tend not to include families with young children. As Stark said, bringing people together can require “creating a common vision that stakeholders share.”
